Computerised and electronic records
Each trust will have stringent security guidelines that you should be especially careful to follow
The great advantage of electronic records is that they have the capacity to integrate information from different sources, which is an enormous boon to multidisciplinary teams.
With electronic patient records, each trust will have stringent security guidelines that you should be especially careful to follow – not leaving a terminal unattended after you’ve logged on, for example.
The upside of computerised record-keeping is that it cuts down on the time taken to wade through paper documents to find relevant information and cuts out duplication.
The downside is that it may not be as easy to make notes anywhere, anytime. Having to log on and off consumes time and may feel like a barrier to making a short entry in a patient’s notes.
Some hospitals use hand-held wireless equipment that can be used at the bedside to call up the patient’s record and add new notes; others have installed bedhead units.
Box 8: Need to know?
The hospital routinely runs electronic audits after a celebrity has stayed in the hospital
An audit carried out after a celebrity had been admitted to hospital in 2007 revealed that more than 50 staff who were not involved in his care had accessed his medical records. Media reports did not specify who the celebrity was, or which hospital it concerned, but the staff were presumably subjected to disciplinary proceedings.
Soon after this, across the Atlantic, George Clooney was admitted to the Palisades Medical Center following a motorbike accident. Subsequent to this, 27 staff who were not involved in his care were suspended without pay for accessing his medical records.
Even further afield, Auckland District Health Board fired one employee and disciplined 20 others “for examining the private medical records of celebrities”.
The hospital routinely runs electronic audits after a celebrity has stayed in the hospital.5
What you can do to minimise the risk of security breaches
- When entering confidential information, ensure that computer terminals and printers can’t be seen by unauthorised people.
- Do not share your passcode with anyone for any reason.
- Change your passcode regularly.
- Never copy unencrypted confidential patient information onto memory sticks or disks (see Box 9).
- Ensure that you use the system in accordance with your trust’s security policy.
Box 9: Memory sticks
If you fail to comply with your trust’s protocols, you could find yourself facing disciplinary proceedings
In March 2003 an estate agent bought a memory stick from a shop in Crewe. On it she found names, addresses, birth dates and clinical information about 13 patients being treated for cancer at the Royal Bolton Hospital.
Many hospitals ban the use of memory sticks, but if they don’t they will have stringent protocols regarding encryption, virus-checking and where they can and cannot be used (eg, whether you can use them on a home computer or not – usually not). If you fail to comply with your trust’s protocols, you could find yourself facing disciplinary proceedings. You will also almost certainly be contravening the Data Protection Act 1998.